Basic Information
| Provider Information | |||||||||
| NPI: | 1003839283 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | TULSA INTERNAL MEDICINE PHYSICIANS, PLLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6966 S UTICA AVE | ||||||||
| Address2: | STE 225 | ||||||||
| City: | TULSA | ||||||||
| State: | OK | ||||||||
| PostalCode: | 741363903 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9184926333 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2000 S WHEELING AVE | ||||||||
| Address2: | STE 1000 | ||||||||
| City: | TULSA | ||||||||
| State: | OK | ||||||||
| PostalCode: | 741045649 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9187488467 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/26/2006 | ||||||||
| LastUpdateDate: | 12/30/2010 | ||||||||
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| AuthorizedOfficialLastName: | HENDRIX | ||||||||
| AuthorizedOfficialFirstName: | PAUL | ||||||||
| AuthorizedOfficialMiddleName: | G | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 9187488467 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 12893 | OK | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 200035090A | 05 | OK | MEDICAID |